Practice Patterns for Organ Preservation in US Patients With Rectal Cancer, 2006-2020.

Importance: In March 2023, the National Comprehensive Cancer Network endorsed watch and wait for those with complete clinical response to total neoadjuvant therapy. Neoadjuvant therapy is highly efficacious, so this recommendation may have broad implications, but the current trends in organ preservation in the US are unknown. Objective: To describe organ preservation trends among patients with rectal cancer in the US from 2006 to 2020. Design, Setting, and Participants: This retrospective, observational case series included adults (aged ≥18 years) with rectal adenocarcinoma managed with curative intent from 2006 to 2020 in the National Cancer Database. Exposure: The year of treatment was the primary exposure. The type of therapy was chemotherapy, radiation, or surgery (proctectomy, transanal local excision, no tumor resection). The timing of therapy was classified as neoadjuvant or adjuvant. Main Outcomes and Measures: The primary outcome was the absolute annual proportion of organ preservation after radical treatment, defined as chemotherapy and/or radiation without tumor resection, proctectomy, or transanal local excision. A secondary analysis examined complete pathologic responses among eligible patients. Results: Of the 175 545 patients included, the mean (SD) age was 63 (13) years, 39.7% were female, 17.4% had clinical stage I disease, 24.7% had stage IIA to IIC disease, 32.1% had stage IIIA to IIIC disease, and 25.7% had unknown stage. The absolute annual proportion of organ preservation increased by 9.8 percentage points (from 18.4% in 2006 to 28.2% in 2020; P < .001). From 2006 to 2020, the absolute rate of organ preservation increased by 13.0 percentage points for patients with stage IIA to IIC disease (19.5% to 32.5%), 12.9 percentage points for patients with stage IIIA to IIC disease (16.2% to 29.1%), and 10.1 percentage points for unknown stages (16.5% to 26.6%; all P < .001). Conversely, patients with stage I disease experienced a 6.1-percentage point absolute decline in organ preservation (from 26.4% in 2006 to 20.3% in 2020; P < .001). The annual rate of transanal local excisions decreased for all stages. In the subgroup of 80 607 eligible patients, the proportion of complete pathologic responses increased from 6.5% in 2006 to 18.8% in 2020 (P < .001). Conclusions and Relevance: This case series shows that rectal cancer is increasingly being managed medically, especially among patients whose treatment historically relied on proctectomy. Given the National Comprehensive Cancer Network endorsement of watch and wait, the increasing trends in organ preservation, and the nearly 3-fold increase in complete pathologic responses, international professional societies should urgently develop multidisciplinary core outcome sets and care quality indicators to ensure high-quality rectal cancer research and care delivery accounting for organ preservation.

New Onset Geriatric Syndromes and One-year Outcomes Following Elective Gastrointestinal Cancer Surgery.

OBJECTIVE: To assess whether older adults who develop geriatric syndromes following elective gastrointestinal surgery have poorer 1-year outcomes. BACKGROUND: Within 10 years, 70% of all cancers will occur in older adults ≥65 years old. The rise in older adults requiring major surgery has brought attention to age-related complications termed geriatric syndromes. However, whether postoperative geriatric syndromes are associated with long-term outcomes is unclear. METHODS: A population-based retrospective cohort study using the New York State Cancer Registry and the Statewide Planning and Research Cooperative System was performed including patients >55 years with pathologic stage I-III esophageal, gastric, pancreatic, colon, or rectal cancer who underwent elective resection between 2004 and 2018. Those aged 55 to 64 served as the reference group. The exposure of interest was a geriatric syndrome [fracture, fall, delirium, pressure ulcer, depression, malnutrition, failure to thrive, dehydration, or incontinence (urinary/fecal)] during the surgical admission. Patients with any geriatric syndrome within 1 year of surgery were excluded. Outcomes included incident geriatric syndrome, 1-year days alive and out of the hospital, and 1-year all-cause mortality. RESULTS: In this study, 37,998 patients with a median age of 71 years without a prior geriatric syndrome were included. Of those 65 years or more, 6.4% developed a geriatric syndrome. Factors associated with an incident geriatric syndrome were age, alcohol/tobacco use, comorbidities, neoadjuvant therapy, ostomies, open surgery, and upper gastrointestinal cancers. An incident geriatric syndrome was associated with a 43% higher risk of 1-year mortality (hazard ratio, 1.43; 95% confidence interval, 1.27-1.60). For those aged 65+ discharged alive and not to hospice, a geriatric syndrome was associated with significantly fewer days alive and out of hospital (322 vs 346 days, P < 0.0001). There was an indirect relationship between the number of geriatric syndromes and 1-year mortality and days alive and out of the hospital after adjusting for surgical complications. CONCLUSIONS: Given the increase in older adults requiring major surgical intervention, and the establishment of geriatric surgery accreditation programs, these data suggest that morbidity and mortality metrics should be adjusted to accommodate the independent relationship between geriatric syndromes and long-term outcomes.

Mediating Factors Between Race and Time to Treatment in Colorectal Cancer.

BACKGROUND: Previous disparities research has demonstrated that underrepresented racial minority patients have worse colorectal cancer outcomes and that they experience unnecessary delays in time to treatment. These delays may explain worse colorectal cancer outcomes for minority patients and serve as a marker of inequalities in our healthcare system. OBJECTIVE: This study aims to quantify the mechanisms that contribute to this disparity in treatment delay. DESIGN: This is a retrospective analysis of colorectal cancer patients who underwent elective resection from 2004 to 2017. A causal inference mediation analysis using the counterfactual framework was utilized to estimate the extent to which racial disparities among patient factors explain the racial disparities in time to treatment. Mediators included income, education, comorbidities, insurance, and hospital type. SETTINGS: This study was conducted at hospitals participating in the National Cancer Database. PATIENTS: Stage I-III colorectal cancer patients, ≥18 years old, who underwent elective resection from 2004 through 2017 were included. MAIN OUTCOMES MEASURES: The primary measures were indirect effects of mediators between race and delayed time to treatment. RESULTS: Of the 504,405 patients (370,051 colon and 134,354 rectal), 10%, 5%, and 4% were black, Hispanic, and other. In multivariable models, compared to white patients, these patients had 25%, 27%, and 17% greater odds of delayed treatment. Mediation analyses suggested that 43%, 20%, and 31% of the treatment delay among them could be removed if an intervention equalized income, education, comorbidities, insurance, and hospital type to that of white patients. Treatment at an academic hospital explained 15% to 32% of the racial disparity and was the most potent mediator. LIMITATIONS: This study was limited by its retrospective design and failure to capture all meaningful mediators. CONCLUSIONS: Black, Hispanic, and other colorectal cancer patients experience treatment delays when compared to white patients. Equalization of the mediators used in this study could reduce treatment delays by 20% to 43% depending on the racial/ethnic group. Future research should identify other causes of racial disparities in treatment delay and intervene accordingly. See Video Abstract at http://links.lww.com/DCR/B871 . FACTORES MEDIADORES ENTRE LA RAZA Y EL TIEMPO HASTA EL TRATAMIENTO EN EL CNCER COLORECTAL: ANTECEDENTES:Investigaciones anteriores sobre disparidades han demostrado que los pacientes de minorías raciales subrepresentados tienen peores resultados de cáncer colorrectal y que experimentan retrasos innecesarios en el tiempo de tratamiento. Estos retrasos pueden explicar los peores resultados del cáncer colorrectal para los pacientes de minorías y servir como un marcador de desigualdades en nuestro sistema de salud.OBJETIVO:Este estudio tiene como objetivo cuantificar los mecanismos que contribuyen a esta disparidad en el retraso del tratamiento.DISEÑO:Este es un análisis retrospectivo de pacientes con cáncer colorrectal que se sometieron a resección electiva entre 2004 y 2017. Se utilizó un análisis de mediación de inferencia causal utilizando el marco contra factual para estimar hasta qué punto las disparidades raciales entre los factores del paciente explican las disparidades raciales en el tiempo hasta el tratamiento. Los mediadores incluyeron ingresos económicos, educación, comorbilidades, seguro médico y tipo de hospital.AJUSTES:Este estudio se realizó en hospitales que participan en la Base de datos nacional del cáncer.PACIENTES:Se incluyeron pacientes con cáncer colorrectal en estadio I-III, ≥18 años, que se sometieron a resección electiva entre 2004 y 2017.PRINCIPALES RESULTADOS MEDIDAS:Las principales mediciones fueron el efecto indirecto de los mediadores entre la raza y el retraso en el tratamiento.RESULTADOS:De los 504,405 pacientes (370,051 de colon, 134,354 rectal), 10%, 5%, 4% eran negros, hispanos, y otros, respectivamente. En modelos multivariables, en comparación con los pacientes blancos, estos pacientes tenían un 25%, 27%, y 17% más de probabilidades de retrasar el tratamiento. Los análisis de medición sugirieron que el 43%, 20%, 31% del retraso del tratamiento entre, respectivamente, podría eliminarse si una intervención igualara los ingresos económicos, la educación, las comorbilidades, el seguro médico y el tipo de hospital a los de los pacientes blancos. El tratamiento en un hospital académico demostró entre el 15% y el 32% de la disparidad racial y fue el mediador más potente.LIMITACIONES:Este estudio estuvo limitado por su diseño retrospectivo; falla en capturar a todos los mediadores significativos.CONCLUSIONES:Los pacientes negros, hispanos y otros con cáncer colorrectal experimentan retrasos en el tratamiento en comparación con los pacientes blancos. La igualación de los mediadores utilizados en este estudio podría reducir los retrasos en el tratamiento en un 20-43%, según el grupo racial / étnico. Las investigaciones futuras deberían identificar otras causas de disparidades raciales en el retraso del tratamiento e intervenir sobre ellas. Consulte Video Resumen en http://links.lww.com/DCR/B871 . (Traducción-Dr. Yolanda Colorado ).

Impact of delay in adjuvant therapy for gallbladder adenocarcinoma.

BACKGROUND: Receipt of adjuvant therapy for gallbladder adenocarcinoma (GBAC) is associated with a survival benefit. This study sought to identify whether delays in initiation of adjuvant therapy among patients with resected GBAC impacts long-term survival. METHODS: Patients with stage II and III GBAC who underwent a curative-intent resection followed by adjuvant chemotherapy or chemoradiation between 2004 and 2017 were queried from the National Cancer Data Base. Descriptive statistics and multivariate models were constructed to determine the relationship between timely (<12 weeks) and delayed (>12 weeks) adjuvant therapy and overall survival (OS). RESULTS: A total of 871 patients with GBAC were identified. The median time to receipt of adjuvant chemotherapy was 67 days and the median time to receipt of adjuvant chemoradiation was 69 days. After controlling for all factors, treatment at an Academic/Research center was the only variable associated with timely receipt of adjuvant therapy. However, after controlling for clinically relevant factors, the timing of adjuvant therapy did not impact OS (delayed: HR 0.93, 95% CI: 0.46-1.85; P = .83). CONCLUSION: Current guidelines support the use of adjuvant therapy following resection of GBAC. This national cohort study demonstrates that delays in adjuvant therapy >12 weeks did not impact long-term survival.

Disparities in Care Access to Liver-Directed Therapy Among Medicare Beneficiaries with Colorectal Cancer Liver Metastasis.

BACKGROUND: Liver-directed therapies (LDT) are important components of the multidisciplinary care of patients with colorectal cancer liver metastases (CRCLM) that contribute to improved long-term outcomes. Factors associated with receipt of LDT are poorly understood. PATIENTS AND METHODS: Patients > 65 years old diagnosed with CRCLM were identified within the Medicare Standard Analytic File (2013-2017). Patients with extrahepatic metastatic disease were excluded. Mixed-effects analyses were used to assess patient factors associated with the primary outcome of LDT, defined as hepatectomy, ablation, and/or hepatic artery infusion chemotherapy (HAIC), as well as the secondary outcome of hepatectomy. RESULTS: Among 23,484 patients with isolated CRCLM, only 2004 (8.5%) received LDT, although resectability status could not be determined for the entire cohort. Among patients who received LDT, 61.7% underwent hepatectomy alone, 28.1% received ablation alone, 8.5% underwent hepatectomy and ablation, and 1.8% received HAIC either alone (0.8%) or in combination with hepatectomy and/or ablation (0.9%). Patient factors independently associated with lower odds of LDT included older age, female sex, Black race, greater comorbidity burden, higher social vulnerability index, primary rectal cancer, synchronous liver metastasis, and further distance from a high-volume liver surgery center (p < 0.05). Results were similar for receipt of hepatectomy. CONCLUSIONS: Despite the well-accepted role of LDT for CRCLM, only a small proportion of Medicare beneficiaries with CRCLM receive LDT. Increasing access to specialized centers with expertise in LDT, particularly for Black patients, female patients, and those with higher levels of social vulnerability or long travel distances, may improve outcomes for patients with CRCLM.

Disparities in access to care among patients with appendiceal or colorectal cancer and peritoneal metastases: A medicare insurance-based study in the United States.

Background: Prior studies attempting to identify disparities in the care of patients with appendiceal (AC) or colorectal cancer (CRC) with peritoneal metastasis (PM) are limited to single-institution, highly selected patient populations. This observational cohort study sought to identify factors associated with specialty care for Medicare beneficiaries with AC/CRC-PM. Materials and methods: Patients >65 years old in the United States diagnosed with AC/CRC and isolated PM were identified within the Medicare Standard Analytic File (2013-2017). Mixed-effects analyses assessed patient factors associated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) and outpatient consultation with a peritoneal surface malignancy (PSM) surgeon, and Cox proportional-hazards analysis compared 3-year overall survival (OS) between patients receiving CRS/HIPEC versus systemic therapy alone. Results: Among 7,653 patients, only 250 (3.3%) underwent CRS/HIPEC. Among those individuals who did not undergo CRS/HIPEC (N=7,403), only 475 (6.4%) had outpatient consultation with a PSM surgeon. Patient factors independently associated with lower odds of CRS/HIPEC and PSM surgery consultation included older age, greater comorbidity burden, higher social vulnerability index, and further distance from a PSM center (p<0.05). CRS/HIPEC was independently associated with better 3-year OS compared with systemic therapy alone (HR=0.29, 95%CI=0.21-0.38). Conclusion: An exceedingly small proportion of Medicare beneficiaries with AC/CRC-PM undergo CRS/HIPEC or even have an outpatient consultation with a PSM surgeon. Significant disparities in treatment and access to care exist for patients with higher levels of social vulnerability and those that live further away from a PSM center. Future research and interventions should focus on improving access to care for these at-risk patient populations.

Social determinants of health Z-codes and postoperative outcomes after colorectal surgery: A national population-based study.

BACKGROUND: We sought to evaluate the impact of social determinants of health (SDOH) on postoperative outcomes following colorectal surgery. METHODS: This retrospective cohort study used PearlDiver-Mariner, an all-payer insurance claims database. Patients who underwent colectomy or proctectomy between 2010 and 2020 were included. SDOH were identified using International Classification of Diseases diagnosis codes. Outcomes were compared using multivariable regression models. RESULTS: The 30-day postoperative complication rate among 333,387 patients (mean age, 59 years; 58% female) was 27%. Approximately 5% of patients reported at least one SDOH at baseline. SDOH were not associated with length of stay but were associated with higher odds of 30-day postoperative complications (OR:1.16, 95% CI:1.12-1.20), including urinary tract infection (OR:1.27, 95% CI:1.20-1.35) anastomotic leak (OR:1.22, 95% CI:1.16-1.28), pneumonia (OR:1.19, 95% CI:1.11-1.27), deep vein thrombosis (OR:1.13, 95% CI:1.02-1.23), sepsis (OR:1.12, 95% CI:1.07-1.18), disruption of wound (OR:1.12, 95% CI:1.03-1.21), and acute kidney injury (OR:1.04, 95% CI:0.99-1.10). CONCLUSIONS: SDOH Z-codes were associated with worse postoperative complications following colorectal surgery and may help target high-risk patients.

An assessment of left-digit bias in the treatment of older patients with potentially curable rectal cancer.

BACKGROUND: Patient age is associated with poorer rectal cancer treatment compliance. However, it is unknown whether left-digit bias (disproportionate influence of leftmost age digit) influences this association. METHODS: The patients diagnosed with stage I-III rectal cancer between 2006 to 2017 in the National Cancer Database were identified. The association between age and receipt of guideline-adherent care was assessed using mixed-effects multivariable analyses. RESULTS: Among 97,960 patients, 46.2% received guideline-adherent overall treatment and 73.3% underwent guideline-adherent surgical resection. Of those who underwent guideline-adherent surgery, 86.4% received guideline-adherent radiotherapy and 56.6% received guideline-adherent chemotherapy. After risk-adjustment, each decade increase in age was associated with 36% decreased odds of guideline-adherent therapy (odds ratio = 0.64, 95% confidence interval = 0.63-0.65). Patients aged 58 to 59 (odds ratio = 1.15, 95% confidence interval = 1.02-1.27) and 78 to 79 (odds ratio = 1.28, 95% confidence interval = 1.08-1.51) had higher odds of guideline-adherent overall treatment compared with patients aged 60 and 80, respectively. However, there were no significant differences in the receipt of guideline-adherent treatment between patients aged 60 vs 61-62 and 80 vs 81-82. CONCLUSION: Older patients with rectal cancer are less likely to receive guideline-adherent care, and a left-digit bias is present. Geriatric assessment-guided treatment decisions could help mitigate this bias.

Liver-Directed Treatment Options Following Liver Tumor Recurrence: A Review of the Literature.

Recurrence following curative-intent hepatectomy for colorectal cancer liver metastasis, hepatocellular carcinoma, or cholangiocarcinoma is unfortunately common with a reported incidence as high as 75%. Various treatment modalities can improve survival following disease recurrence. A review of the literature was performed using PubMed. In addition to systemic therapy, liver-directed treatment options for recurrent liver disease include repeat hepatectomy, salvage liver transplantation, radiofrequency or microwave ablation, intra-arterial therapy, and stereotactic body radiation therapy. Repeat resection can be consider for patients with limited recurrent disease that meets resection criteria, as this therapeutic approach can provide a survival benefit and is potentially curative in a subset of patients. Salvage liver transplantation for recurrent hepatocellular carcinoma is another option, which has been associated with a 5-year survival of 50%. Salvage transplantation may be an option in particular for patients who are not candidates for resection due to underlying liver dysfunction but meet criteria for transplantation. Ablation is another modality to treat patients who recur with smaller tumors and are not surgical candidates due to comorbidity, liver dysfunction, or tumor location. For patients with inoperable disease, transarterial chemoembolization, or radioembolization with Yttrium-90 are liver-directed intra-arterial therapy modalities with relatively low risks that can be utilized. Stereotactic body radiation therapy is another palliative treatment option that can provide a response and local tumor control for smaller tumors.

Is robotic utilization associated with increased minimally invasive colorectal surgery rates? Surgeon-level evidence.

BACKGROUND: It is unclear whether robotic utilization has increased overall minimally invasive colorectal surgery rates or if robotics is being adopted instead of laparoscopy. The goal was to evaluate whether increasing robotic surgery utilization is associated with increased rates of overall colorectal minimally invasive surgery. METHODS: The Statewide Planning and Research Cooperative System (New York) was used to identify patients undergoing elective colectomy or proctectomy from 2009 to 2015. Individual surgeons were categorized as having increasing or non-increasing robotic utilization (IRU or non-IRU, respectively) based on the annual increase in the proportion of robotic surgery performed. The odds of surgical approach across the study period were evaluated with multinomial regression. RESULTS: Among 72,813 resections from 2009 to 2015, minimally invasive-surgery increased (47-61%, p < 0.0001). For colectomy, overall minimally invasive-surgery rates increased (54-66%, p < 0.0001), laparoscopic remained stable (53-54%), and robotics increased (1-12%). For proctectomy, overall minimally invasive-surgery rates increased (22-43%, p < 0.0001), laparoscopic remained stable (20-21%), and robotics increased (2-22%). Over the study period, 2487 surgeons performed colectomies. Among 156 surgeons with IRU for colectomies, robotics increased (2-29%), while laparoscopy decreased (67-44%), and open surgery decreased (31-27%). Overall, surgeons with IRU performed minimally invasive colectomies 73% of the time in 2015 versus 69% in 2009. Over the study period, 1131 surgeons performed proctectomies. Among 94 surgeons with IRU for proctectomies, robotics increased (3-42%), while laparoscopy decreased (25-15%), and open surgery decreased (73-44%). Overall, surgeons with IRU performed minimally invasive proctectomy 56% of the time in 2015 versus 27% in 2009. Patients in the latter study period had 57% greater odds of undergoing robotic surgery. CONCLUSIONS: Overall, minimally invasive colorectal resections increased from 2009 to 2015 largely due to increasing robotic utilization, particularly for proctectomies.

A Scoping Review of the Classification, Diagnosis, and Management of Hepatic Adenomas.

BACKGROUND: Hepatic adenomas (HA), or hepatocellular adenomas, are benign, solid liver lesions that develop in otherwise normal livers, often in the setting of increased estrogen levels. While considered a benign tumor, there is a risk for substantial complications such as hemorrhage and malignant transformation. We review the diagnosis, classification, and potential therapeutic management options for patients with HA. METHODS: A scoping narrative review was conducted based on recent literature regarding classification, diagnosis, and management of HA. RESULTS: While HAs are typically considered benign, complications such as hemorrhage and malignant transformation may occur in approximately 25% and 5% of patients, respectively. Recent advances in imaging and molecular profiling have allowed for the classification of HAs into subtypes allowing for patient risk stratification that helps guide management. Surgical resection should be considered in asymptomatic patients who are male, have an adenoma ≥5 cm in diameter, or have the ß-catenin-activated subtype due to an increased risk of hemorrhage and/or malignant transformation. CONCLUSION: Molecular profiling has aided in the stratification of patients relative to the risk of complications to predict better the potential behavior of HAs.

Variation in the volume-outcome relationship after rectal cancer surgery in the United States: Retrospective study with implications for regionalization.

BACKGROUND: Previous studies have demonstrated improved outcomes for patients with rectal cancer treated at higher-volume hospitals. However, little is known whether heterogeneity in this effect exists. The objective was to test whether the effect of increased annual rectal cancer resection volume on outcomes is consistent across all hospitals treating rectal cancer. METHODS: Adult stage I to III patients who underwent surgical resection for rectal adenocarcinoma from 2004 to 2016 were identified in the National Cancer Database. RESULTS: We included 120,522 patients treated at 763 hospitals in this retrospective cohort study. Higher volume was linearly and incrementally related to outcomes in unadjusted analyses. In adjusted models, for an average patient at the average hospital, the effect of increasing the annual caseload of rectal cancer resections by 20 resections per year was associated with 8%, (hazard ratio = 0.92, 95% confidence interval = 0.87, 0.97), 18% (odds ratio = 0.82, 95% confidence interval = 0.70, 0.98), and 16% (odds ratio = 0.84, 95% confidence interval = 0.73, 0.95) relative reductions in 5-year overall survival, 30-, and 90-day mortality, respectively, and with a 19% (odds ratio = 1.19, 95% confidence interval = 1.04, 1.36) relative increase in the rate of neoadjuvant chemoradiation. These effects varied by individual hospitals such that 39% of hospitals do not see any benefit in 5-year overall survival associated with higher volumes. Increased volume was associated with lower positive circumferential resection margin rates at 19% of the hospitals. CONCLUSION: This study confirms that higher-volume hospitals have improved outcomes after rectal cancer surgery. However, there exists significant variation in these effects induced by individual within-hospital effects. Regionalization policies may need to be flexible in identifying the hospitals that would achieve enhanced benefits from treating a larger volume of patients.

Factors affecting short-term survival in patients older than 85 treated with resection for stage II and III colon cancer.

BACKGROUND: Patients ≥85 years of age have high rates of colon cancer but disproportionately poor outcomes. Factors affecting short-term (90-day) survival in patients ≥85 undergoing surgery for stage II and III colon cancer were examined to identify potentially modifiable factors to improve outcomes. METHODS: The New York State Cancer Registry and Statewide Planning Research and Cooperative System were queried for patients ≥85 years who underwent colectomy for stage II and III colon cancer between 2004 and 2012. Regression analyses were performed for factors associated with 90-day mortality and stratified by elective and nonelective surgery. RESULTS: In total, 3,779 patients ≥85 years of age underwent colectomy between 2004 and 2012 for stage II or III colon cancer. Of these, 48.4% underwent nonelective colectomy, 79.9% had an open operation, and 90-day survival was 83.2%. Worse survival was associated with nonelective surgery (odds ratio = 3.81, 95% confidence interval = 3.03-4.89). Improved survival in the nonelective and overall groups was associated with a minimally invasive operation (nonelective group: odds ratio = 0.35, 95% confidence interval = 0.21-0.58; overall group: odds ratio = 0.50, 95% confidence interval = 0.36-0.73) and discharged to another health care facility (nonelective group: odds ratio = 0.30, 95% confidence interval = 0.22-0.39; overall group: odds ratio = 0.42, 95% confidence interval = 0.33-0.53). High surgeon annual operating volume was associated with improved survival in the elective and nonelective groups (P < .001). CONCLUSION: Factors associated with greater odds of 90-day mortality in this population include nonelective surgery, preoperative weight loss, and multiple comorbidities, whereas a minimally invasive approach was associated with lower mortality. Potential areas to improve outcomes in this population include using a multidisciplinary team approach, addressing frailty preoperatively when possible, and potentially reconsidering screening guidelines for colorectal cancer to reduce rates of emergency operations.

Is Textbook Oncologic Outcome a Valid Hospital-Quality Metric after High-Risk Surgical Oncology Procedures?

BACKGROUND: "Textbook oncologic outcome" (TOO) is a composite quality measure representing the "ideal" outcome for patients undergoing cancer surgery. This study sought to assess the validity of TOO as a metric to evaluate hospital quality. METHODS: Patients who underwent curative-intent resection of gastric, pancreatic, colon, rectal, lung, esophageal, bladder, or ovarian cancer were identified in the National Cancer Database (2006-2017). Cancer site-specific TOO was defined as adequate lymph node yield, R0 resection, non-length-of-stay outlier, no hospital readmission, and receipt of guideline-concordant chemotherapy and/or radiation. Mixed-effects analyses estimated the adjusted TOO rate for each hospital stratified by cancer site. The association between hospital adjusted TOO rates and 5-year overall survival was assessed using mixed-effects Cox proportional hazards analyses. RESULTS: Among 852,988 cancer resections, the TOO rate varied across cancer sites as follows: stomach (31.8%), pancreas (25%), colon (66.9%), rectum (33.6%), lung (35.1%), esophagus (31.2%), bladder (43%), and ovary (44.7%). After characterization of adjusted hospital TOO rates into quintiles, an incremental improvement in overall survival was observed, with higher adjusted TOO rates. Similarly, with the adjusted hospital TOO rate treated as a continuous variable, there was a significant 4% to 12% improvement in overall survival for every 10% increase in the adjusted hospital TOO rate for gastric (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.85-0.91), pancreatic (HR, 0.90; 95% CI, 0.88-0.93), colon (0.93; 95% CI, 0.91-0.94), rectal (HR, 0.90; 95% CI, 0.87-0.93), lung (HR, 0.96; 95% CI, 0.95-0.97), esophageal (HR, 0.93; 95% CI, 0.90-0.95), bladder (HR, 0.94; 95% CI, 0.91-0.97), and ovarian (HR, 0.96; 95% CI, 0.94-0.98) cancer. CONCLUSIONS: A direct association exists between adjusted hospital TOO rates and survival after high-risk cancer procedures. As a valid hospital metric, TOO can be used to compare the overall quality of cancer care across hospitals.

Variation in outcomes across surgeons meeting the Leapfrog volume standard for complex oncologic surgery.

BACKGROUND: A large body of evidence supports regionalization of complex oncologic surgery to high-volume surgeons at high-volume hospitals. However, whether there is heterogeneity of outcomes among high-volume surgeons at high-volume hospitals remains unknown. METHODS: Patients who underwent esophagectomy, lung resection, pancreatectomy, or proctectomy for primary cancer were identified within the Medicare 100% Standard Analytic File (2013-2017). Mixed-effects analyses assessed the association between Leapfrog annual volume standards for surgeons (esophagectomy ≥7, lung resection ≥15, pancreatectomy ≥10, proctectomy ≥6) and hospitals (esophagectomy ≥20, lung resection ≥40, pancreatectomy ≥20, proctectomy ≥16) relative to postoperative complications and 90-day mortality. Additional analyses using New York's all-payer Statewide Planning and Research Cooperative System (2004-2015) were performed. RESULTS: Among 112,154 Medicare beneficiaries, high-volume surgeons at high-volume hospitals were associated with lower adjusted odds of complications (esophagectomy: odds ratio [OR], 0.73 [95% CI, 0.61-0.86]; lung resection: OR, 0.88 [95% CI, 0.82-0.94]; pancreatectomy: OR, 0.73 [95% CI, 0.66-0.80]; proctectomy: OR, 0.92 [95% CI, 0.85-0.99]) and 90-day mortality (esophagectomy: OR, 0.60 [95% CI, 0.44-0.76]; lung resection: OR, 0.82 [95% CI, 0.73-0.93]; pancreatectomy: OR, 0.66 [95% CI, 0.56-0.76]; proctectomy: OR, 0.74 [95% CI, 0.65-0.85]). For the average patient at the average high-volume hospital, there was a 2-fold difference in the adjusted complication rate between the best-performing and worst-performing high-volume surgeon for all operations (esophagectomy, 28%-55%; lung resection, 7%-21%; pancreatectomy, 16%-35%; proctectomy, 16%-28%). Wide variation was also present in adjusted 90-day mortality for esophagectomy (3.5%-9.3%). Results from New York's all-payer database were similar. CONCLUSIONS: Even among high-volume surgeons meeting the Leapfrog volume standards, wide variation in postoperative outcomes exists. These findings suggest that volume alone should not be used as a quality indicator, and quality metrics should be continuously evaluated across all surgeons and hospital systems. LAY SUMMARY: Previous studies have demonstrated a surgical volume-outcome relationship for high-risk operations-that is high-volume surgeons and hospitals that perform a specific surgical procedure more frequently have better outcomes for that operation. Although most high-volume surgeons had better outcomes, this study demonstrated that some high-volume surgeons did not have better outcomes. Therefore, volume is an important factor but should not be the only factor considered when assessing the quality of a surgeon and a hospital for cancer surgery.

Significant Variation in Blood Transfusion Practice Persists Following Adolescent Idiopathic Scoliosis Surgery.

STUDY DESIGN: Retrospective case control study. OBJECTIVE: To review current transfusion practise following Adolescent Idiopathic Scoliosis (AIS) surgery and assess risks of complication from transfusion in this cohort. SUMMARY OF BACKGROUND DATA: No study to date has investigated variation in blood transfusion practices across surgeons and hospitals following AIS surgery. METHODS: Data were extracted from the Statewide Planning and Research Cooperative System. Using International Classification of Diseases (ICD-9) all patients with (ICD-9) code for AIS (737.30) ("idiopathic scoliosis") and underwent spinal fusion between 2000 and 2015 were included. Bivariate and mixed-effects logistic regression analyses were performed to assess patient, surgeon, and hospital factors associated with perioperative allogeneic red blood cell transfusion. Additional multivariable analyses examined the association between transfusion and infectious complications. RESULTS: Of the 7689 patients who underwent AIS surgery, 21.1% received a perioperative blood transfusion. After controlling for patient factors, wide variation in risk-adjusted transfusion rates was present with a 10-fold difference in transfusion rates observed across surgeons (4.4%-46.1%) and hospitals (5.1%-50%). Patient factors did not explain any of the surgeon or hospital variation. Use of autologous blood transfusion, higher surgeon procedure volume, and greater surgeon years in practice were independently associated with lower odds of allogeneic blood transfusion (P < 0.001), and surgeon and hospital characteristics explained 45% of surgeon variation but only 2.4% of hospital variation. Allogeneic blood transfusion was independently associated with postoperative wound infection (OR = 1.87, 95% CI = 1.20-2.93), pneumonia (OR = 1.68, 95% CI = 1.26-2.44), and sepsis (OR = 2.42, 95% CI = 1.11-5.83). CONCLUSION: Significant variation exists across both surgeons and hospitals in perioperative blood transfusion utilization following AIS surgery. Use of autologous blood transfusion and implementing institutional transfusion protocols may reduce unwarranted variation and potentially decrease infectious complication rates.Level of Evidence: 3.

One-year patient survival correlates with surgeon volume after elective open abdominal aortic surgery.

OBJECTIVE: Volume-outcome relationships in surgery have been well established. Studies have shown that high-volume surgeons provide improved outcomes in performing open abdominal aneurysm repairs. The hypothesis of this study was that high-volume surgeons provide superior short-term and midterm outcomes of elective open aortic operations compared with low-volume surgeons. METHODS: We evaluated patients undergoing elective open abdominal aortic aneurysm repair, aortofemoral bypass, and aortomesenteric bypass by board-certified vascular surgeons using the New York Statewide Planning and Research Cooperative System database from 2002 to 2014. The Contal and O'Quigley technique was used to estimate a cut point objectively and provided an estimate of significance. A division using average yearly volumes (averaged during 3 years) of seven or more cases and fewer than seven cases per year returned the highest Q statistic, and this grouping was used to classify high-volume and low-volume provider groups. Rates of complications during index hospitalization, length of stay, 30-day survival, 90-day survival, 1-year survival, and cause of death were analyzed using mixed effect models. RESULTS: In 118 hospitals during the 13-year period, 266 board-certified vascular surgeons performed 244 aortomesenteric bypasses, 4202 aortofemoral bypasses, and 6126 abdominal aortic aneurysm repairs. High-volume surgeons' rates of complications during index hospitalization, 30-day survival, 90-day survival, and 1-year survival were superior to those of low-volume surgeons. The Contal and O'Quigley technique returned an estimate of seven operations per year for optimal survival during 1 year. This cutoff is associated with an adjusted 1-year hazard ratio of 0.687 (P = .003), a 2.69% difference in 1-year all-cause survival (P = .003), and a 1.76-day reduction in the mean length of stay at index hospitalization (P < .001). Higher volume surgeons showed a 25.0%, 43.4%, 42.4%, 40.6%, and 45.0% reduction in postoperative rates of acute renal failure (P < .001), hemorrhage (P < .001), pulmonary failure (P < .001), sepsis (P < .001), and venous thromboembolism (P < .001), respectively. Abdominal abscess, acute renal failure, hemorrhage, myocardial infarction, and sepsis were associated with increased cardiovascular cause-specific mortality after open aortic operations (P < .001). CONCLUSIONS: These data demonstrate that high-volume surgeons performing elective open aortic operations provide reduced complications and improved short-term and midterm survival compared with low-volume surgeons. Clinical and postoperative variables that are associated with increased cardiovascular cause-specific mortality are also identified. These data provide further evidence that elective open abdominal vascular surgery should be centralized to high-volume surgeons.